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Abstract: Treatment planning for radiation therapy involves trade-offs with respect to different clinical goals. Typically, the dose distribution is evaluated based on few statistics and dose-volume histograms. Particularly for stereotactic treatments, the spatial dose distribution represents further criteria, e.g., when considering the gradient between subregions of volumes of interest. The authors have studied how to consider the spatial dose distribution using a multicriteria optimization approach.The authors have extended a stepwise multicriteria optimization approach to include criteria with respect to the local dose distribution. Based on a three-dimensional visualization of the dose the authors use a software tool allowing interaction with the dose distribution to map objectives with respect to its shape to a constrained optimization problem. Similarly, conflicting criteria are highlighted and the planner decides if and where to relax the shape of the dose distribution.To demonstrate the potential of spatial multicriteria optimization, the tool was applied to a prostate and meningioma case. For the prostate case, local sparing of the rectal wall and shaping of a boost volume are achieved through local relaxations and while maintaining the remaining dose distribution. For the meningioma, target coverage is improved by compromising low dose conformality toward noncritical structures. A comparison of dose-volume histograms illustrates the importance of spatial information for achieving the trade-offs.The results show that it is possible to consider the location of conflicting criteria during treatment planning. Particularly, it is possible to conserve already achieved goals with respect to the dose distribution, to visualize potential trade-offs, and to relax constraints locally. Hence, the proposed approach facilitates a systematic exploration of the optimal shape of the dose distribution.